OBJECTIVE Sagittal craniosynostosis constricts transverse skull growth, with possible neurocognitive sequelae. While the degree of sagittal suture fusion has been shown to influence the degree of dysmorphology, it is unknown if it impacts functional findings, including elevated intracranial pressure (ICP). The purpose of this study was to determine associations between the degree of sagittal suture fusion and optical coherence tomography (OCT) surrogates suggestive of increased ICP in patients with nonsyndromic sagittal craniosynostosis. METHODS Three-dimensional CT head images of patients with sagittal craniosynostosis were analyzed in Materialise Mimics and parietal bones were manually isolated to determine the percentage fusion of the sagittal suture. Retinal OCT was performed prior to the cranial vault procedure with analysis for thresholds that correlate with elevated ICP. The degree of sagittal suture fusion was compared with OCT retinal parameter measurements using Mann-Whitney U-tests, Spearman’s correlations, and multivariate logistic regression models controlled for age. RESULTS Forty patients (31 males) with nonsyndromic sagittal craniosynostosis at a mean (± SD) age of 3.4 ± 0.4 months were included in this study. OCT surrogates of elevated ICP (maximal retinal nerve fiber layer [RNFL] thickness and maximal anterior projection [MAP]) were not associated with total sagittal suture fusion (p > 0.05). Maximal RNFL thickness was positively associated with increased percentage of posterior one-half (rho = 0.410, p = 0.022) and posterior one-third (rho = 0.417, p = 0.020) sagittal suture fusion. MAP was also positively associated with increased percentage of posterior one-half (rho = 0.596, p < 0.001) and posterior one-third (rho = 0.599, p < 0.001) sagittal suture fusion. Multivariate logistic regression models revealed increased percentage of posterior one-half (p = 0.048) and posterior one-third (p = 0.039) sagittal suture fusion predicted ICP > 20 mm Hg. CONCLUSIONS Increased percentage fusion of the posterior sagittal suture, but not total suture, was positively associated with retinal changes indicative of increased ICP. These findings suggest suture fusion leading to increased ICP may be region specific.
Background: Cleft and craniofacial centers require significant investment by medical institutions, yet variables contributing to their academic productivity remain unknown. This study characterizes the elements associated with high academic productivity in these centers. Methods: The authors analyzed cleft and craniofacial centers accredited by the American Cleft Palate-Craniofacial Association. Variables such as university affiliation; resident training; number of plastic surgery, oral-maxillofacial, and dental faculty; and investment in a craniofacial surgery, craniofacial orthodontics fellowship program, or both, were obtained. Craniofacial and cleft-related research published between July of 2005 and June of 2015 was identified. A stepwise multivariable linear regression analysis was performed to measure outcomes of total publications, summative impact factor, basic science publications, total journals, and National Institutes of Health funding. Results: One hundred sixty centers were identified, comprising 920 active faculty, 34 craniofacial surgery fellowships, and eight craniofacial orthodontic fellowships; 2356 articles were published in 191 journals. Variables most positively associated with a high number of publications were craniofacial surgery and craniofacial orthodontics fellowships (β = 0.608), craniofacial surgery fellowships (β = 0.231), number of plastic surgery faculty (β = 0.213), and university affiliation (β = 0.165). Variables most positively associated with high a number of journals were craniofacial surgery and craniofacial orthodontics fellowships (β = 0.550), university affiliation (β = 0.251), number of plastic surgery faculty (β = 0.230), and craniofacial surgery fellowship (β = 0.218). Variables most positively associated with a high summative impact factor were craniofacial surgery and craniofacial orthodontics fellowships (β = 0.648), craniofacial surgery fellowship (β = 0.208), number of plastic surgery faculty (β = 0.207), and university affiliation (β = 0.116). Variables most positively associated with basic science publications were craniofacial surgery and craniofacial orthodontics fellowships (β = 0.676) and craniofacial surgery fellowship (β = 0.208). The only variable associated with National Institutes of Health funding was craniofacial surgery and craniofacial orthodontics fellowship (β = 0.332). Conclusion: Participation in both craniofacial surgery and orthodontics fellowships demonstrates the strongest association with academic success; craniofacial surgery fellowship, university affiliation, and number of surgeons are also predictive.
Donor-specific antibodies (DSA) to human leukocyte antigen increase the risk of accelerated rejection and allograft damage and reduce the likelihood of successful transplantation. Patients with full-thickness facial burns may benefit from facial allotransplantation. However, they are at a high risk of developing DSA due to standard features of their acute care.A 41-year-old male with severe disfigurement from facial burns consented to facial allotransplantation in 2014; panel reactive antibody score was 0%. In August of 2015, a suitable donor was found. Complement-dependent cytotoxicity crossmatch was negative; flow cytometry crossmatch was positive to donor B cells. An induction immunosuppression strategy consisting of rabbit antithymocyte globulin, rituximab, tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone taper was designed. Total face, scalp, eyelid, ears, and skeletal subunit allotransplantation was performed without operative, immunological, or infectious complications. Maintenance immunosuppression consists of tacrolimus, MMF, and prednisone. As of posttransplant month 24, the patient has not developed acute rejection or metabolic or infectious complications.To our knowledge, this is the first report of targeted B cell agents used for induction immunosuppression in skin-containing vascularized composite tissue allotransplantation. A cautious approach is warranted, but early results are promising for reconstructive transplant candidates given the exceptionally high rate of acute rejection episodes, particularly in the first year, in this patient population.
Background: Although the surgical microscope remains the most common tool used for visual magnification for microsurgical anastomoses in free tissue transfer, loupe-only magnification for free flap breast reconstruction has been demonstrated to be safe and effective. To evaluate the loupe-only technique in lower extremity free flap reconstruction, the authors compared perioperative outcomes between microsurgical anastomoses performed with loupe magnification versus a surgical microscope. Methods: The authors conducted a two-institution retrospective study of soft-tissue free flaps for traumatic below-knee reconstruction. Optimal subgroup matching was performed using patient age, defect location, flap type (muscle versus fasciocutaneous), and time from injury (acute, <30 days; remote, >30 days) for conditional logistic regression analysis of perioperative outcomes. Results: A total of 373 flaps met inclusion criteria for direct matched comparison of anastomoses performed with loupe magnification ( n = 150) versus a surgical microscope ( n = 223). Overall major complication rates were 15.3 percent: take-back for vascular compromise, 7.8 percent; partial flap failure, 7.8 percent; and total flap loss, 5.4 percent. No differences were observed between the loupe and microscope groups regarding major complications (14.0 percent versus 16.1 percent; OR, 0.78; 95 percent CI, 0.38 to 1.59), take-back for vascular compromise (5.3 percent versus 9.4 percent; OR, 0.51; 95 percent CI, 0.19 to 1.39), any flap failure (13.3 percent versus 13.0 percent; OR, 1.21; 95 percent CI, 0.56 to 2.64), partial flap failure (7.3 percent versus 8.1 percent; OR, 1.04; 95 percent CI, 0.43 to 2.54), and total flap loss (6.0 percent versus 4.9 percent; OR, 1.63; 95 percent CI, 0.42 to 6.35). Conclusions: Perioperative complication rates, take-backs for vascular compromise, partial flap losses, and total flap failure rates were not significantly different between the matched loupe and microscope groups. Overall microsurgical success rates in traumatic lower extremity free flap reconstruction appear to be independent of the microsurgical technique used for visual magnification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Background: The perception that complications are more frequent earlier in the medical academic year, known as the “July phenomenon,” has been studied in several specialties, with conflicting results. This phenomenon has yet to be studied in plastic surgery; therefore, this study sought to evaluate the presence of the July phenomenon within plastic surgery. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was accessed, and cases from 2005 to 2014 where “plastic surgery” was listed as the surgical specialty were identified. Only cases with trainee involvement were included for analysis. Included cases were stratified into two groups based on calendar-year quarter of admission. The quarter-3 group included 2451 cases performed during July to September of each calendar year, and the remaining-quarters group included 7131 cases performed in the remaining quarters of each calendar year. Complication rates for 24 complications of interest for quarter-3 and remaining-quarters cases with trainee involvement were calculated, chi-square analysis was used to compare complication rates between groups. Multivariate regression analysis was performed to control for potential confounders. Results: Comparison of complication rates within operations with trainee involvement showed a statistically significant increase in quarter-3 versus remaining-quarters groups for superficial wound infection (0.032 versus 0.023; p = 0.046) and wound dehiscence (0.010 versus 0.006; p = 0.034). No significant difference was found for the remaining 22 complications evaluated. Conclusion: This study of a nationwide surgical database found that for the vast majority of complications coded in the database, the rates do not increase in the beginning of the academic year. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
To the Editor: The non-lifesaving nature of facial transplantation (FT) has raised concerns over the procurement of a facial allograft (FA) and allocated solid organs (SO) from a single donor. In response, FT teams have described their experiences performing simultaneous (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar) and asynchronous procurement (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar,3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). One unanimous conclusion is that the safe procurement of lifesaving organs must be given priority during the donor operation (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar, 2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar, 3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). Another consistent viewpoint is that the ideal location for FA procurement is the FT team’s home institution (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar,3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). This is due to several factors, including reduced ischemia time and guaranteed availability of specialized microsurgical equipment. Additionally, operating room staff familiarity with the surgical and ethical aspects of FT is crucial; the duration of FA procurement is longer than that of SO, and its graphic nature may distress previously unexposed team members. Operative time may increase further with more complex FA designs (3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar), which may result in professional fatigue (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar) and complicate coordination with the team performing the recipient dissection. Considering these challenges, the NYU FT team collaborated with LiveOn NY when determining a logistical algorithm prioritizing surgical team safety, SO allograft integrity, and reduced FA ischemia time (Figure 1). Upon FA donor identification and consent, the resulting protocol involves the transfer of the brain-dead donor to (and at the expense of) NYU. To ensure donor safety, a critical care unit–like environment is recreated in an ambulance. On arrival, preoperative evaluations that may not be possible in smaller hospital settings can be performed, including computed tomography, angiography, and cardiac catheterization. The donor is monitored in a critical care unit until all operative teams are confirmed. FA recovery begins and proceeds until source vessels are isolated. SO procurement ensues, and the FT team returns to the operating table after cross-clamp is performed; subsequently, allografts are simultaneously recovered and preserved for transplantation and/or transportation. At all times, NYU SO transplant surgeons are available to coordinate teams, and are prepared to rapidly procure SO allografts should the donor become unstable while non-NYU procurement teams are in transit. On August 12, 2015 a FA donor was identified as an ideal match to a candidate listed at NYU. Following the protocol described above, donor transportation proceeded without complications the following day. On August 14, 2015 FA procurement was performed, lasting 12 h; the donor remained stable throughout, and SO recovery was never at risk. Multiple non-NYU transplant teams successfully procured their allocated SO allografts after cross-clamp. Despite brief mention in the plastic surgery literature of another interhospital donor transport protocol for FT (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar), to our knowledge, this is the first description of such an algorithm in the transplant literature. A study of SO procurements requiring donor transport demonstrated improved efficiency and considerable cost-savings without donor compromise (4Jendrisak MD Hruska K Wagner J Chandler D Kappel D Hospital-independent organ recovery from deceased donors: A two-year experience.Am J Transplant. 2005; 5: 1105-1110Crossref Scopus (5) Google Scholar), an important precedent for NYU’s protocol. Furthermore, while NYU only offers SO allograft recovery as a contingency, reports of liver procurement by local teams show equivalent posttransplant outcomes (5Salvalaggio PR Ferraz-Neto BH Liver grafts procured by other transplant teams do not affect posttransplantation outcomes.Transpl Proc. 2012; 44: 2293-2296Crossref PubMed Scopus (5) Google Scholar). Emphasizing SO allograft integrity and donor safety, FT and SO transplant teams can work efficiently to recover allocated allografts for their respective patients. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
Introduction: Although single institution studies have analyzed various animal attacks, there has not been multicenter investigation into dog bites in children. The purpose of this study was to characterize national trends and investigate the characteristics of pediatric dog bites. Methods: Aretrospective cohort study was conducted of pediatric dog bite injuries in the United States from 2015 to 2020 using the Pediatric Health Information System national database. Patient characteristics, injury locations, and need for intervention were analyzed. Mann–Whitney U test, Pearson chi-square, and Fisher exact test, and linear multivariate regressions were performed for statistical analysis of data values; statistical significance was maintained at P < 0.05. Results: A total of 56,106 patients were included, majority male (55.1%) with a median age 6.8 years (interquartile range 3.5–10.6). Incidence peaked in July (median =1217) with nadirs in February (median = 760). A substantial increase in bites was seen per overall Emergency Department presentations during the pandemic. Most common bite location was the head (62.1%), followed by the upper extremity (25.1%). Relative proportions of dog bites to the face gradually decreased with age (B = –3.4%/year, P< 0.001), whereas proportions to the upper extremities (B = + 1.9%/year, P < 0.001) and lower extremities (B = + 1.6%/year, P = 0.002) gradually increased with age. Overall, 8.0% patients required repair in the operating suite. injuries isolated to the head (OR= 2.6, P < 0.001) and those to multiple anatomic regions were more likely to require operative intervention [operating room (OR= 2.6, P < 0.001)]. Conclusions: Dog bites most commonly occur during the summer in school-aged boys. Toddlers disproportionately suffer injuries to the head, with a trend towards upper extremity bites in teenagers. The coronavirus disease 2019 pandemic ushered a spike in dog bite presentations among Emergency Department visits, further underscoring the need for targeted educational initiatives to halt the persistence of these preventable injuries.
